CLUBFOOT TREATMENT BY THE PONSETI METHOD IN YAOUNDE, ABOUT A COHORT OF 74 CASES.

12 [1-36] months. The sex ratio was 1.9 boy for 1 girl. The mean initial Pirani score was 5 [4-6] over 6. The average number of plasters before tenotomy was 5 [4-7]. We did 58 (78.38%) percutaneous tenotomies of the Achilles tendon under local anesthesia. All children were prescribed IOWA abduction foot braces permanently (23H/24) for 3 months, and during sleep for up to 4-5 years. We had 63 (85.13%) very good results after an average follow-up of 20 [12-40] months, and recommend this method for those working in conditions similar to ours.

Clubfoot is a common congenital invalidating pathology. The method of Ponseti, its reference treatment, remains little known in Cameroon: no local studies on the subject. This is why we conducted a prospective evaluation of clubfoot treatment at Promhandicam-Yaoundé, a center specialized on the Ponseti method, from August 1st 2013, to November 30th 2016. We followed and treated 47 children with 74 talipes equino varus feet, by the method of Ponseti. There were 27 (57.45%) bilateral clubfeet, and 20 (42.55%) unilateral including 14 (70%) unilateral rights feet out of the 20. The average age was 12  months. The sex ratio was 1.9 boy for 1 girl. The mean initial Pirani score was 5 [4][5][6] over 6. The average number of plasters before tenotomy was 5 [4][5][6][7]. We did 58 (78.38%) percutaneous tenotomies of the Achilles tendon under local anesthesia. All children were prescribed IOWA abduction foot braces permanently (23H/24) for 3 months, and during sleep for up to 4-5 years. We had 63 (85.13%) very good results after an average follow-up of 20  months, and recommend this method for those working in conditions similar to ours.  (11), 953-959 954 treatment of CTEV by the Ponseti method in a group of 74 patients followed in our context by a specialized team using the Ponseti method. We did not find any local studies on this topic.

Methodology:-
We followed a prospective cohort of all children aged 0 to 3 years treated by the Ponseti method for idiopathic CTEV at the PROMHANDICAM Center in Mimboman, Yaoundé, during our 40-month study period, from August 1 st , 2013 to November 30 th , 2016. All patients were initially assessed by the Pirani score and classified as mild (Score 1 to 2), moderate (score 2 to 4) or severe (sore 5 to 6). We have included all club feet, whether light, moderate or severe. We included untreated (never treated and aged less than 2 years old), neglected (never treated and older than 2 years), recurrent (after Ponseti treatment) and complex (initially treated with method other than that of Ponseti). All children were also assessed on a general basis for secondary clubfoot. We excluded secondary clubfeet due to ankle burns, osteomyelitis, neurological diseases such as spina bifida or cerebral palsy, amniotic bands, tibia agenesis and arthrogryposis. All patients then benefited from the Ponseti method in 3 steps: manipulations and casting (Figure 1), tenotomy when indicated( Figure 2) and IOWA abduction braces ( Figure 3). Before the application of each plaster, there were manipulations to soften the posterior tibial, the triceps sural and the flexor tendons of the toes (common flexor tendon of the last 4 toes and the halluci longus); which allowed to gain amplitudes of movement ensuring the progressive correction. The plaster numbered 1 corrected the plantar cavus. Plaster numbered 2, 3 and 4 progressively corrected the abduction while plaster number 5 reduced the equinus. Plaster numbered 5 was always placed in a position of maximum abduction with an automatic reduction of the valgus of the hind foot and the equine ( Figure 1). Some CTEV required a little more or a little less plasters for each step depending on their severity.
Practically, we have: initially assessed the children according to the Pirani score, checked the exclusion criteria, before admitting the child and starting the treatment sessions. The children were treated once a week. At each sesssion, we had to:

To properly install the child
The installation for plasters requires the child to be calm. It is useful to have a trained assistant, because two trained personnels are needed for casting. It is also sometimes necessary to have the help of parents. The assistant holds the foot while the operator carries out the weekly re-evaluation and the correction of the day, after having located the lateral head of the talus.

Locating the head of the talus precisely
This step was essential. First, the lateral malleolus should be palpated with the thumb / index finger of one hand while the metatarsals and toes were held by the other hand. Then we slid our thumb / index finger forward to feel the head of the talus.

Make a streching
It was done for 3 to 5 minutes to gradually correct the CTEV. The manipulation consists of a correction of the cavus with a small agravation of the supination, then a progressive abduction around a pivot constituted by the head of the talus previously localized and stabilized. This progressive abduction leads through kinematic coupling, to an automatic correction of the varus of the hind foot and a small reduction of the equine. All components of clubfoot deformity, except for the equinus ankle, are progressively corrected.

Put the plaster
The foot being maintained in the corrected position by the assistant, the operator first applied the Soffband®, then a plantar splint, before puting the cast with the plaster of Paris or Biplatrix®. The Soffband® role is to protect the child's skin so that it is not compressed between two hard planes that are the bone on the one hand and plaster on the other hand. The padding (Soffband®) overflowed a little at the ends, preventing skin wounds.

Mold the plaster
It was not necessary to try to force the correction with the plaster, nor to apply a constant pressure on the lateral head of the talus with the thumb, but to apply successive pressures and releases in order to avoid having painful cutaneous areas. For the right club foot, for example, the left thumb of the operator is on the lateral head of the talus while the right hand molds the forefoot by holding it in abduction (two hands holding technique). The plantar face was carefully molded to prevent deformation in flat foot or convex foot. The heel was well molded by applying the 955 plaster well above the large calcaneal tuberosity. The malleoli were also carefully molded. The calcaneus was not touched during the entire manipulation and molding phase in order to allow its automatic rotation to progressively arise. The molding was dynamic, with frequent changes of finger position to avoid excessive pressure on any site. We also continued to mold the plaster until it hardened.
Extend the cast to the thigh Initially below the knee, the cas was then extended to the root of the thigh, with a splint on the anterior aspect of the knee, the knee being flexed at 90°.

Make the final cuts of the plaster
We left in place the plantar part of the plaster that supports the toes (to maintain the gain obtained by stretching the plantar flexors of the toes, the dorsal surface of the toes being released up to the metatarsophalangeal joints to count all the toes and monitor them: edema, coloration, recolouration time, mobility. Make a tenotomy before the last plaster. It was preceded by informed consent and verification of the four tenotomy criteria / indications : head of the talus completely covered, abduction of 50 to 70°, heel in valgus and equinus at least 0°, but less than 15°. We also checked the contraindications ( general pathology, respiratory tract infection, skin infection in progress) and asked for allergies, past medical illness, preoperative laboratory assessment. An anesthetist was allways informed and the monitoring and resuscitation equipment available, verified and functional. After removal of the previous plaster, it was necessary to take the measurements of the foot and order the corresponding foot abduction braces of the corresponding size, to prepare the post tenotomy step.
In cases where the dorsiflexion remained below 15°, a tenotomy was then indicated. After surgical washing of the hands, sterile gloving, we used to disinfect with iodinated polyvidone (the red Betadine®, drying and then the yellow Betadine®), do sterile field and then infiltrate 0.5ml (per foot) of lidocaine (Xylocaine®) 1% (without exceed 0.3ml / kg / patient, maximum dose) 1.5 cm from the calcaneal insertion of the Achilles tendon. The tenotomy was performed by a trauma orthopedic surgeon, after a 0.5 cm vertical postero-medial cutaneous incision, with the surgical blade number 15 ( Figure 2). The incision was made 3 minutes after infiltration of the local anesthetic, tendon stretched by a maximum dorsiflexion ensured by the operative aid, blade parallel to the anterior face of the Achilles tendon previously carefully palpated. The blade was then inserted into a safety triangle that separates the Achilles tendon from the more anterior elements that are from medial to posterior: the tendon of the posterior tibial muscle, the flexor digitorum longus tendon common to the last 4 toes, the posterior tibialis artery, the posterior tibial vein, the tibial nerve, and the flexor halluci longus tendon. Rotationg the blade towards the back permitted the tenotomy (cross section of the Achilles tendon from front to back) to be performed. This was usually audible or perceptible and followed by dorsiflexion gain of more than 15 °, and palpation of the tendon discontinuity. A Kelly hemostasis forceps was used to check the completeness of the tenotomy and it was then completed with fine scissors (tenotomy scissors), if necessary. After the tenotomy, a digital compression of 5 to 10 minutes using a gauze was applied to control the bleeding and a dry dressing was then placed. This last cast was kept for 3 weeks. In case of insufficient gain of dorsiflexion, a streching to increase it more was done (without all causing an osteoclasy of the anterior of the tibia cortex), after 10 days and a new plaster put in place for 21 days.

Order and apply the abduction IOWA braces (Figure 3)
The measurements of the splints were taken just before the tenotomy, at the time of the last plaster, to allow the orthoprosthesist to manufacture them so that they are available directly at the time of removal of the last plaster (21 days after the tenotomy). The wearing of IOWA foot abduction braces continued over 4 -5 years. Initially they are worn 23h / 24 for 3 months then only during nap and sleep. The children who were walking already at the beginning of the treatment had only the night splints. Splint monitoring was done after one week, six weeks, three months and then every six months. An evaluation at the end of treatment was also made using the Pirani score. Continuous monitoring of complications: between two appointments, the accompanying parent was given specific instructions for monitoring the child, plaster, toes, bleeding (after tenotomy), abduction foot braces and had a phone number he could call back 24 hours a day, 7 days a week, in case of a problem.

Discussion:-
We carried out an interventional prospective study on a cohort of 74 clubeet. Our intervention was a correction by the Ponseti's method. We did an evaluation before and after. Of the 74 foot idiopathic bots, we had 85.13% very good results. However, our sample size was not very large. We had 6 (8.10%) lost to follow up. The 5 recurrences we had were related to the misuse of the abduction foot braces; These cases recovered after additional castings, without tenotomy. 50% of girls were treated without Achilles tendon tenotomy against 12.13% of boys and the sex ratio is in favor of boys (1.  Table 2 with those of other authors. Despite our small sample size, our results are good but can be improved to be similar to those of other authors: We must reduce the number of lost to follow up, improve the compliance to the foot abduction braces , initiate treatment early enough, and continue monitoring long enough to expect the same percentages of good results as other authors.

Conclusion:-
The management of idiopathic clubfoot by the Ponseti method involves three simple steps: successive manipulations and casting, Achilles tendon tenotomy and wearing foot abduction braces. It has very good results in our context. This is why we recommend it to all those working in conditions similar to ours. Start treatment early. Most cases need a tenotmy and wearing of foot abduction braces up to 4 -5 years must be rigorously respected to avoid recurrence.

Ethical considerations
Data confidentiality was provided at each step and we asked for informed consent before any treatment, and before tenotomy.